Clinical Corner - March 2023

When I trained as a surgeon in the 1970’s, almost all patients went to the operating room for a breast lump to make a diagnosis of cancer or benign disease, breast cancer was treated by radical mastectomy and neoadjuvant treatment was a distant thought! Essentially all diagnostic biopsies were surgical until image-guided stereotactic needle biopsy was introduced to select patients who needed to undergo therapeutic surgery (as opposed to the then-standard “diagnostic” breast surgery) for malignant disease.

Utilizing the same conceptual framework, several studies have recently been undertaken and published testing the hypothesis that image-guided biopsy can accurately identify patients with a pathological complete response (pCR) and subsequently where any surgery might be omitted. The MD Anderson multicenter trial for eliminating breast cancer surgery in patients responding  to neoadjuvant systemic therapy (NST) has reached accrual. Patients on this study had initial T1/T2 N0/1 unicentric triple-negative or HER2-positive disease. Patients with residual disease after NST had standard surgery followed by radiotherapy, and those with a pCR did not have breast surgery. Although still early, there have not been any local, regional or distant recurrences in patients on the study.

The important questions, whether women with breast cancer and a pCR can avoid surgery and radiation after NST, can only be answered by keeping meticulous records regarding treatment that are found in our cancer registries!